Menoufia Medical Journal

: 2020  |  Volume : 33  |  Issue : 2  |  Page : 713--716

Laparoscopic inguinal hernia repair in girls using the percutaneous internal ring suturing technique – our own experience

Ramesh Tanger, Aditya P Singh, Arun K Gupta, Vinay Mathur 
 Department of Pediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India

Correspondence Address:
Aditya P Singh
M Ch in Pediatric Surgery, Near the Mali Hostel, Main Bali Road, Falna, Pali 306116, Rajasthan


Objective We evaluate d the usefulness of the percutaneous internal ring suturing (PIRS) technique in girls only. Background PIRS is a percutaneous closure of the internal inguinal ring under the control of a telescope/laparoscope placed through the umbilicus. Material and methods Thirty girls underwent surgery using this method in our institution between 2016 and 2017. We used telescope (3 mm, 0°), spinal needle (20 G), and nonabsorbable polypropylene 3-0 suture. The insufflation pressure in the peritoneal cavity was maintained at 8–10 mmHg. Results We selected the isolated cases of the inguinal hernia in only girls. There was no need of conversion to open surgery in our study. The recurrence was seen in two (6.6%) cases. These were treated by open herniotomy. We did follow-up with local clinical examination only. Conclusion PIRS technique is an alternative for the open inguinal surgery. It is effective and minimally invasive surgery and without visible scar. It is also useful to detect the other abnormalities and can perform other procedure in same session such as contralateral inguinal hernia and umbilical hernia.

How to cite this article:
Tanger R, Singh AP, Gupta AK, Mathur V. Laparoscopic inguinal hernia repair in girls using the percutaneous internal ring suturing technique – our own experience.Menoufia Med J 2020;33:713-716

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Tanger R, Singh AP, Gupta AK, Mathur V. Laparoscopic inguinal hernia repair in girls using the percutaneous internal ring suturing technique – our own experience. Menoufia Med J [serial online] 2020 [cited 2020 Dec 2 ];33:713-716
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Inguinal hernia repair is the most common operative procedure in the children. The open inguinal herniotomy is the gold standard treatment for the pediatric inguinal hernia. However, in recent years, laparoscopic inguinal hernia repair has become more and more popular. In 2004, in Poland, Patkowski introduced a method of laparoscopic herniorrhaphy using his own technique 'percutaneous internal ring suturing (PIRS).' In this technique, he closes the internal inguinal ring percutaneously under the control of a telescope placed in the umbilicus[1],[2],[3]. It is a very simple technique and has many advantages, including the use of only single umbilical port, short operative time, and excellent cosmetic results.

We are presenting here our experience with the PIRS technique at our institute. We did it in girls only owing to our initial learning curve.

 Materials and Methods

Thirty girls underwent PIRS procedure for the congenital indirect inguinal hernia between 2016 and 2017. We used 3-mm telescope with angle view of 0°. The insufflation pressure in the peritoneal cavity was maintained at 8–10 mmHg. We used 20 G spinal needle. The internal opening of the inguinal canal was closed using nonabsorbable 3-0 monofilament polypropylene suture. The wound in the umbilicus was closed by absorbable 4-0 sutures, and the skin was not closed owing to very small (needle tip) size of incision. The patients were discharged on the first postoperative day. We did follow-up after seventh postoperative day and 3 months. At the time of the second follow-up visit (3 months after surgery), parents of all girls were given a questionnaire including recurrent hernia, swelling in the groin, local pain, how quickly the child had resumed physical activity, cosmetic appearance related to scar, and whether there had been any palpable stitches in the groin area.

Surgical technique

Under general anesthesia in supine position, with all aseptic precaution, pneumoperitoneum was created with the veress needle and carbon dioxide. The pressure was kept between 8 and 10 mmHg. A 3-mm trocar was inserted through umbilicus, and a telescope (3 mm and 0°) was placed in the peritoneal cavity through it. We assessed both the internal inguinal rings. We created a needle sized stab incision in the skin exactly at the deep ring. The 20 G spinal needle threaded with 3-0 prolene inserted under vision at inferolateral aspect of deep ring. A loop of prolene was created and the needle was removed, leaving a prolene loop intraperitoneal. The needle was reinserted through the same stab incision after putting the prolene in the needle. We inserted the needle under vision up to peritoneum almost medial aspect of ring, and then needle is manipulated extraperitoneally up to the loop. Then the needle was pushed into the peritoneum near the prolene loop and needle entered in the loop. Thereafter, we pushed the threaded prolene inside the loop. We removed the needle. We pulled out both the ends of previous prolene, which brought intraperitoneal end of second prolene suture. The knot was tied of second suture, leading to complete occlusion of deep inguinal ring under vision. Umbilical incision was closed by single suture, whereas stab incision at deep ring did not need any suturing.

Statistical analysis

We used simple statistics only.


A total of 30 PIRS procedures were performed. All were female children in our study. There were 18 cases of right-side congenital inguinal hernia, eight left side, and four bilateral. Additionally in four girls, an open inguinal canal on the opposite side was found during surgery. There were clinically hidden inguinal hernia and were not recognized before surgery. There were three in right side and one was on left side. These were treated with same technique and in the same session. The age ranged from 3 months to 12 years (mean, 4 years) [Table 1]. Taking into consideration that owing to lack of experience may result in spermatic cord damage by clamping it in the tied knot, we performed our initial cases in girls only. We used a 3-mm telescope in all girls. The angle of the view was 0° in all cases.{Table 1}

The mean operative time was 20 min (minimum, 15 min; maximum, 40 min) – the time taken from the beginning of cleaning the operative field to dressing the umbilicus. In the case of bilateral hernia, the mean operative time was 40 min (minimum, 25 min; maximum, 65 min). There was no case that converted to open. All cases were indirect congenital inguinal hernia. There was no case of hydrocele, gonadal disorder, or umbilical hernia. There was no case of iliac vessel puncture during needle manipulation. All patients operated on with that technique were followed up at least once, at least 3 months after surgery. Parents of all girls were given a questionnaire including recurrent hernia, swelling in the groin, local pain, how quickly the child had resumed physical activity, and cosmetic appearance related to scar. There were only two cases of recurrence. All girls resumed their physical activity after day 2; cosmetic results were excellent without or invisible scar. The scar in the navel was very little visible or almost invisible, and none of the parents raised esthetic objections. There was no swelling in inguinal area and slight pain was observed by two (6.67%) cases. The place of skin puncture above the inguinal canal was not visible in all cases. There was no infection in the surgical wound in any case [Table 2] and [Figure 1], [Figure 2].{Table 2}{Figure 1}{Figure 2}


Indirect hernias are the most common hernia in children. These are the results of a patent processus vaginalis in boys or its analog in girls – canalis nucki[4]. The incidence ranges from 0.8 to 4.4%[5], but the exact incidence is unknown. This type of inguinal hernia is diagnosed 8–10 times more often in boys than in girls, with 60% of cases occurring on the right side and 10% of cases being diagnosed as bilateral hernia. In premature new-borns, the risk of bilateral congenital oblique inguinal hernia increases to 44–55%[6],[7].

The operative treatment is indicated in hernia to avoid complications such as incarceration and strangulation[4],[8]. The herniotomy through the inguinal incision is a traditional surgical approach. The classical approach has been performed for a long time, and it has excellent results, but nowadays laparoscopic hernia repair is becoming more and more popular. It mostly involves only the suturing of the internal inguinal ring. There are many different techniques described[1],[4],[5],[8],[9],[10].

Patkowski (Professor, Medical University of Wroclaw in Poland) developed his own laparoscopic technique (PIRS) of inguinal hernia repair in children. The advantages of the PIRS technique in comparison with the open surgical approach, which is the golden standard for inguinal hernia repair in children, are numerous.

The advantage of this method is that it requires only one umbilical port and the suture is placed at the level of the internal inguinal ring through the puncture point access with an injection needle[1]. This way intra-abdominal suturing is avoided, which requires a very skilled surgeon with a lot of experience and is very time consuming and the procedure leaves only a minimal scar in the area of the umbilicus[1]. The procedure is simple and cheaper, and the operative time is short[1]. The procedure is minimally invasive and does not require an inguinal incision, which is the main cause of postoperative pain[1]. It also enables a diagnosis of a possible contralateral hidden hernia and its repair within the same procedure[1]. The cosmetic effect of laparoscopic surgery was very good. The umbilical scar and needle puncture sites scar were almost invisible. It does not require any specific equipment for the procedure. We used spinal needle in our study despite injection needle because it has a long shaft, so we were comfortable during the manipulation.

Initially only girls were qualified for the procedure, because of the risk of vas deferens injury, which is confirmed by others as well[11],[12],[13],[14],[15],[16],[17]. We also included only girls in our study.

Recurrence rate for open hernia repair ranges from 0.8 to 3.8%[9]. The recurrence rate for laparoscopic repair ranges from 0.7 to 4.5%, which is slight higher[9]. When using the PIRS technique, the recurrence rate is 2.5%, but it significantly decreases with refinement of the technique and gaining experience to 1%.

Owing to the proximity of the vessels, there is a risk of puncturing them with the tip of the injection needle. These bleeding events are limited and can be stopped by applying pressure to the abdominal wall from the outside in the inguinal area. There was no case of needle puncture in our study. In boys, transient hydrocele may develop occasionally after surgery. It spontaneously was reabsorbed within a couple of months[1]. In literature, one case of adhesive ileus has been described as a complication of the PIRS procedure[1]. No such complications were reported in our study. We did not have complications such as palpable stitch and stitch granuloma in our study. Few patients with thin abdominal wall had palpable stitch, but it was our finding, patient did not have any complaints.

A similar study was performed by Erginel et al.[18] in 2016 with comparable results with our study. This study also concluded that the PIRS technique is a safe, simple, and effective procedure in girls. They had also noticed excellent cosmetics results as well as reduced recurrence as in our study.

We did not suture the skin incision in our study; even then there was a better cosmetics result. We used telescope (3 mm, 0°) irrespective of age. It gave better cosmetic results at umbilicus in older girls.

The technique is easier to perform on a patient with a thinner abdominal wall. It was performed as a day surgery; the patient was discharged on the same day. The results were excellent.


Inguinal hernia repair using the PIRS technique allows for visualization of the peritoneal cavity, and thus the ability to detect other abnormalities such as intersex, repair a contralateral open inguinal ring that would be a potential hidden hernia, or repair an umbilical hernia. The PIRS technique is simple, is minimally invasive, has short operative time, has excellent cosmetic results, and allows for a quick return to activities as well as it does not require any specific equipment. We believe that this technique could be a valuable alternative to an open surgical approach in inguinal hernia repair.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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